QUESTION: In patients with, or at high risk of, coronary artery disease (CAD), is an Indo Mediterranean diet more effective
than the conventional step 1 National Cholesterol Education Program (NCEP) prudent diet?

Main outcome measures

Main results

Analysis was by intention to treat. At 2 years, the intervention group consumed more fruits, vegetables, nuts, and legumes
(mean 573 v 231 g/d, p<0.001), consumed more n-3 fatty acids (mean 1.8 v 0.78 g/d, p<0.001), and had lower serum cholesterol concentrations (mean 5.04 v 5.59 mmol/l, p<0.001) than the control group. The intervention group had lower risks of non-fatal MI, sudden cardiac death,
and total cardiac endpoints than the control group; groups did not differ for fatal MI (table).

Conclusion

In patients with, or at high risk of coronary artery disease (CAD), an Indo Mediterranean diet rich in whole grains, fruits,
vegetables, and nuts reduced CAD risk factors and total cardiac events more than a conventional prudent diet.

Commentary

Assistant Professor, The Nethersole School of Nursing The Chinese University of Hong Kong, Hong Kong, China

The protective effect of the Mediterranean diet in developed nations is becoming recognised as an important lifestyle strategy
for reducing progression of CAD.1 However, risk factors for CAD are also an important cause of disease in developing nations.2 Research on lifestyle modification in these countries is limited, and the study by Singh et al provides important new information.

Firstly, although differences in culture, religion, geography, and resources influence dietary patterns, the Mediterranean
diet can be adapted to local conditions. The Indo Mediterranean diet, although similar to the Mediterranean diet, is distinguished
by its focus on fruits, vegetables, nuts, and whole grains. Secondly, such a diet, in addition to other lifestyle changes,
can reduce morbidity and mortality from heart disease compared with a prudent diet. Although 2/3 of patients in both the treatment
and control groups were vegetarian at the start of the trial, the lifestyle modifications incorporating an Indo Mediterranean
diet were still effective. Thirdly, the study findings reinforce recommendations in the developed world that consuming a variety
of fruits, vegetables, and grain products will reduce risk factors of heart attack.3 Whether the Indo Mediterranean diet itself would be broadly acceptable in developed nations is moot, as dramatic alterations
in diet would probably be required.

2 limitations need to be considered. 90% of participants were men, and therefore the effect of the Indo Mediterranean diet
and other lifestyle changes on women remains uncertain. The acceptability of lifestyle modification for women in developing
nations also needs to be investigated before lifestyle trials can be done. A second limitation is that participants were discouraged
from smoking and alcohol use, and encouraged to exercise and use mental relaxation techniques. Although the frequency of these
lifestyle changes apparently did not differ, these factors have also been found to have benefits in the prevention and progression
of heart disease. The absence of an adjusted analysis means it is not possible to isolate potential interactions between these
factors.

Singh et al provide compelling evidence for promoting diets that incorporate aspects of the Mediterranean with local diets for developing
nations. Making minor adaptations is likely to facilitate adoption of dietary recommendations. Based on this study, nurses
should promote additional whole grain consumption and expanded food choices in patient education.